coding strategies

Dealing With Contract Exclusions

BY CLARKE D. NEWMAN, OD, FAAO

GK Chesterton once said, "To be clever enough to get all the money, one must be stupid enough to want it." In my January column, I discussed the fact that it's okay to get paid for what we do. However, you have to want to get paid. No one volunteers to pay you. The situation in which most of us leave the money on the table is when an insurance company doesn't cover our medically necessary contact lens charges.

Common Exclusions

Insurance companies can rightfully refuse to pay for something under two circumstances. First, you filed the claim incorrectly. Second, you have filed for a service that's excluded by a patient's insurance plan.

As we discussed in my last column, the contracts that you sign with insurance companies can and do contain clauses that exclude certain things. Generally, these clauses are designed to reduce the financial exposure of the insurance company by reducing their claims experience.

These exclusions fall into two basic categories. First, a payer will exclude things that it knows it will have to pay for, such as pre-existing conditions. Pre-existing conditions can be short-lived or they can last forever. Insurance companies know that chronic conditions cost them money. So, they'll often exclude these conditions indefinitely. For conditions that last for a finite period of time, payers usually have a defined time for the exclusion.

Second, a payer will exclude certain expensive services unless the employer pays extra for those services. These types of services often include psychiatric services, maternity services and, you guessed it, contact lens services.

Insurance companies frequently exclude contact lens services. They are needed by a relatively small number of subscribers, and when it comes to cutting costs in the high-priced world of insurance purchasing, these services are often the first to go.

Sometimes the Patient is Responsible

First you need to find out for each patient whether there are any exclusions. Might a pre-existing exclusion prohibit coverage of a patient who otherwise would be covered? Or are contact lenses excluded altogether?

A complete exclusion will affect only the cost of the lens materials and the diagnostic fitting, which fall under codes 92310 to 92313. All other services are still covered. Remember, an insurance contract defines only what services the payer will pay for; the contract does not define what services you can provide.

Certainly, everything that you bill should be medically necessary, according to the definition of medical necessity that we discussed in February. It would be unethical to bill for services that aren't so. Remember, we're trying to maximize our reimbursements ethically.

For services that aren't covered, the answer is very simple. Either patients pay for them or you decide to give them away for free. Now, you might have a compelling ethical reason for giving them away based on financial need. You might check with your accountant about those donated services as tax write-offs for charitable contributions.

Don't give your services away for any other reason. Remember, it's not your fault that these patients have these conditions. They should pay for the valuable services that you provide if their insurance company will not.

It's important for patients to know up front what they will have to pay for. It's often not as much as they think if the other services are billed correctly.

Next month, we'll talk about consultation service codes. CLS

Dr. Newman has been in private practice in Dallas, Texas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine and refractive surgery.